Nokea
How can the nurse help monitor effectiveness of therapy for the patient with a pneumothorax and chest-drainage system?
- A. Palpate for crepitus
- B. Document color and amount of sputum
- C. Auscultate lung sounds
- D. Monitor suction level
Correct Answer: C
Rationale: The correct answer is C: Auscultate lung sounds. By auscultating lung sounds, the nurse can assess for changes in breath sounds which can indicate improvement or deterioration in the patient's condition. This helps monitor the effectiveness of therapy for a pneumothorax and chest-drainage system. Palpating for crepitus (A) is not directly related to monitoring therapy effectiveness. Documenting sputum color and amount (B) is important but does not specifically monitor therapy effectiveness. Monitoring suction level (D) is crucial but does not directly assess the patient's response to therapy.
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When instructing the client diagnosed with hyperparathyroidism about diet, the nurse should stress the importance of which of the following?
- A. Restricting fluids
- B. Forcing fluids
- C. Restricting sodium
- D. Restricting potassium
Correct Answer: C
Rationale: The correct answer is C: Restricting sodium. In hyperparathyroidism, there is an excess of parathyroid hormone leading to increased calcium levels. Sodium can worsen calcium excretion, exacerbating the condition. Restricting sodium can help reduce calcium loss.
A: Restricting fluids is not necessary unless the client has kidney issues.
B: Forcing fluids may not be beneficial and can lead to fluid overload.
D: Restricting potassium is not typically necessary unless the client has kidney issues.
A 16 y.o. girl is diagnosed with genital herpes. She is tearful and as she asks what she can do to prevent complications of the disease. Based on the data provided, which nursing diagnosis is appropriate for her plan of care?
- A. Risk for transmission of infection
- B. Pain
- C. Health-seeking behaviours
- D. Ineffective sexuality pattern
Correct Answer: A
Rationale: The correct answer is A: Risk for transmission of infection. This is appropriate because the girl has genital herpes, which is a sexually transmitted infection (STI) that can be transmitted to others through sexual contact. Therefore, the main concern is preventing the spread of the infection to others. Pain (B) is a symptom of herpes but not the primary concern here. Health-seeking behaviors (C) may be relevant for education and prevention, but not the immediate focus. Ineffective sexuality pattern (D) is not directly related to the risk of transmission of infection in this case.
Which of the ff actions should the nurse perform to monitor for electrolyte imbalances and dehydration in a client with a neurologic deficit?
- A. Measure intake and output
- B. Perform the mini-mental status
- C. Use the Glasgow Coma scale examination
- D. Assess vital signs
Correct Answer: A
Rationale: The correct answer is A: Measure intake and output. Monitoring intake and output is crucial in assessing electrolyte imbalances and dehydration in clients with neurologic deficits. Electrolyte imbalances can lead to neurological complications, so accurate monitoring is essential. Mini-mental status and Glasgow Coma scale are assessments of mental status, not electrolyte balance. Vital signs can provide some information, but intake and output measurement is more specific for assessing electrolyte imbalances and dehydration.
Which of the ff instructions should a nurse give a client with Hodgkin’s disease who is at risk of impaired skin integrity? Choose all that apply
- A. Trim nails short
- B. Keep the neck in midline
- C. Use mild soap
- D. Support and protect bony prominences
Correct Answer: B
Rationale: Step 1: Keeping the neck in midline helps prevent compression of the lymphatic vessels in the neck, reducing the risk of impaired skin integrity in Hodgkin's disease.
Step 2: This position also helps maintain proper blood flow and lymphatic drainage in the neck area.
Step 3: Trimming nails short, using mild soap, and supporting bony prominences are not directly related to preventing impaired skin integrity in Hodgkin's disease.
Summary: Choice B is correct as it directly addresses the specific risk factor of impaired skin integrity in Hodgkin's disease, while the other choices are not as relevant to this particular concern.
Just as the nurse was entering the room, the patient who was sitting on his chair begins to have a seizure. Which of the following must the nurse do first?
- A. Ease the patient to the floor
- B. Insert a padded tongue depressor between his jaws
- C. Lift the patient and put him on the bed
- D. Restraint patient’s body movement
Correct Answer: A
Rationale: The correct answer is A: Ease the patient to the floor. This is the first step because it helps prevent injury during a seizure. Lowering the patient to the floor prevents falls and protects the patient's head. Choices B, C, and D are incorrect. Choice B can cause injury or obstruct the airway, choice C involves unnecessary movement, and choice D can lead to further harm or injury. It is crucial to prioritize safety and prevent harm during a seizure episode.